Autores: Xiaofeng Deng, MD , Zihao Zhang, PhD, Yan Zhang, MD , PhD, Dong Zhang, MD , PhD,
Rong Wang, MD , PhD, Xun Ye, MD , PhD, Long Xu, MD , PhD, Bo Wang, PhD, Kai Wang, MD ,
and Jizong Zhao, MD
Departments of Neurosurgery and Neuroradiology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (NCRC-ND); Center of Stroke, Beijing Institute for Brain Disorders; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; State Key Laboratory of Brain and Cognitive Science, Beijing MRI Center for Brain Research, Institute of Biophysics, Chinese Academy of Sciences; and Graduate School, University of Chinese Academy of Sciences, Beijing, China.
Journal of Neurosurgery
Posted online on November 6, 2015.
Link del Abstract: http://thejns.org/doi/abs/10.3171/2015.5.JNS15767?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
This document discusses the use of multi-modal CT scanning in evaluating patients with cerebrovascular disease. It begins by introducing ischemic stroke as a leading cause of disability and mortality. It then discusses how CT has evolved as a non-invasive imaging tool to evaluate carotid artery pathology and intracranial vessels. In particular, it describes the use of CT angiography (CTA) to assess vessel lumen and plaque characteristics, and CT perfusion (CTP) to provide information on brain vascular physiology and identify ischemic penumbra. The document provides details on CT protocols for CTA and CTP, and discusses how findings from these techniques can predict stroke risk and guide treatment decisions. It focuses on how CTA allows evaluation of
This document provides guidelines for using multimodality imaging to evaluate patients with repaired tetralogy of Fallot (TOF). It describes the role of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT), nuclear scintigraphy, and angiography. Echocardiography and CMR are well-suited for longitudinal follow-up due to lack of radiation. CMR is considered the reference standard for assessing right ventricular size and function and pulmonary regurgitation. A multimodality approach is recommended to comprehensively evaluate the complex anatomy and physiology while considering each patient's needs and institutional resources.
Percutaneous Transcatheter Mitral Valve ReplacementShadab Ahmad
Symptomatic mitral regurgitation (MR) conveys significant morbidity and mortality. However, many patients with severe MR are not treated with surgery due to advanced age, left ventricular (LV) dysfunction, or other comorbidities. This unmet clinical need has driven the development of safer, catheter-based treatments for mitral valve disease.
Transcatheter mitral valve repair can be safe and effective in patients with suitable anatomy.
This study compared the diagnostic accuracy of three computed tomography (CT) fractional flow reserve (FFR) algorithms - the Huo-Kassab model, Murray law model, and Transluminal Attenuation Gradient (TAG) method - in detecting hemodynamically significant coronary stenosis of intermediate severity (25-69%). The study found that the TAG method had the highest accuracy (92%) in detecting invasive FFR values of ≤0.8, followed by the Huo-Kassab and Murray law models. While all three CT FFR algorithms improved discrimination compared to CT angiography alone, the TAG method showed the best correlation with invasive FFR measurements. The study concludes that CT FFR can help reduce unnecessary invasive
This document summarizes the current status of surgical and transcatheter mitral valve repair. It notes that mitral valve repair surgery has low risks and good outcomes when appropriate procedures are used. However, around 50% of symptomatic patients with severe mitral regurgitation are denied surgery. New transcatheter techniques are being developed as alternatives to surgery, including the MitraClip edge-to-edge repair device, annuloplasty devices, and future prospects for transcatheter mitral valve replacement. Early experiences with MitraClip show it reduces mitral regurgitation in many patients but long-term outcomes need further study. An individualized approach is needed to determine the best repair option based on a patient's anatomy,
This document summarizes a presentation on using non-invasive FFRCT (computed tomography-derived fractional flow reserve) to assess coronary artery disease. It discusses studies showing FFRCT has high diagnostic accuracy compared to invasive FFR measurements. The PLATFORM trial found FFRCT was associated with fewer unnecessary invasive angiograms showing no obstructive lesions compared to usual care. FFRCT also led to lower healthcare costs without differences in clinical outcomes. A larger randomized trial is still needed to establish FFRCT's role in routine clinical care.
Coronary artery bypass grafting (CABG) with adjunctive endarterectomy (CE) is a useful technique for treating complex cases of diffuse coronary artery disease. CE aims to completely revascularize the heart by removing coronary artery blockages. While results of CE are debated, one study found acceptable mid-term results with CE and CABG, including a 2.7% in-hospital mortality rate. The study also compared outcomes of patients treated postoperatively with single antiplatelet therapy (aspirin) versus dual antiplatelet therapy (aspirin and clopidogrel). No significant differences in outcomes were found between the two groups in the mid-term follow up period, though dual antiplate
1) A study evaluated the impact of incorporating FFRCT data with CT angiogram results compared to CT angiogram alone in 200 patients.
2) The addition of FFRCT data led to a change in management in 36% of cases, similar to prior studies using invasive FFR.
3) This suggests non-invasive FFRCT can mimic invasive FFR's ability to refine management decisions made based on angiography alone. A definitive randomized trial is now needed to establish FFRCT's role as a default screening test for patients with chest pain.
This document discusses the use of multi-modal CT scanning in evaluating patients with cerebrovascular disease. It begins by introducing ischemic stroke as a leading cause of disability and mortality. It then discusses how CT has evolved as a non-invasive imaging tool to evaluate carotid artery pathology and intracranial vessels. In particular, it describes the use of CT angiography (CTA) to assess vessel lumen and plaque characteristics, and CT perfusion (CTP) to provide information on brain vascular physiology and identify ischemic penumbra. The document provides details on CT protocols for CTA and CTP, and discusses how findings from these techniques can predict stroke risk and guide treatment decisions. It focuses on how CTA allows evaluation of
This document provides guidelines for using multimodality imaging to evaluate patients with repaired tetralogy of Fallot (TOF). It describes the role of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT), nuclear scintigraphy, and angiography. Echocardiography and CMR are well-suited for longitudinal follow-up due to lack of radiation. CMR is considered the reference standard for assessing right ventricular size and function and pulmonary regurgitation. A multimodality approach is recommended to comprehensively evaluate the complex anatomy and physiology while considering each patient's needs and institutional resources.
Percutaneous Transcatheter Mitral Valve ReplacementShadab Ahmad
Symptomatic mitral regurgitation (MR) conveys significant morbidity and mortality. However, many patients with severe MR are not treated with surgery due to advanced age, left ventricular (LV) dysfunction, or other comorbidities. This unmet clinical need has driven the development of safer, catheter-based treatments for mitral valve disease.
Transcatheter mitral valve repair can be safe and effective in patients with suitable anatomy.
This study compared the diagnostic accuracy of three computed tomography (CT) fractional flow reserve (FFR) algorithms - the Huo-Kassab model, Murray law model, and Transluminal Attenuation Gradient (TAG) method - in detecting hemodynamically significant coronary stenosis of intermediate severity (25-69%). The study found that the TAG method had the highest accuracy (92%) in detecting invasive FFR values of ≤0.8, followed by the Huo-Kassab and Murray law models. While all three CT FFR algorithms improved discrimination compared to CT angiography alone, the TAG method showed the best correlation with invasive FFR measurements. The study concludes that CT FFR can help reduce unnecessary invasive
This document summarizes the current status of surgical and transcatheter mitral valve repair. It notes that mitral valve repair surgery has low risks and good outcomes when appropriate procedures are used. However, around 50% of symptomatic patients with severe mitral regurgitation are denied surgery. New transcatheter techniques are being developed as alternatives to surgery, including the MitraClip edge-to-edge repair device, annuloplasty devices, and future prospects for transcatheter mitral valve replacement. Early experiences with MitraClip show it reduces mitral regurgitation in many patients but long-term outcomes need further study. An individualized approach is needed to determine the best repair option based on a patient's anatomy,
This document summarizes a presentation on using non-invasive FFRCT (computed tomography-derived fractional flow reserve) to assess coronary artery disease. It discusses studies showing FFRCT has high diagnostic accuracy compared to invasive FFR measurements. The PLATFORM trial found FFRCT was associated with fewer unnecessary invasive angiograms showing no obstructive lesions compared to usual care. FFRCT also led to lower healthcare costs without differences in clinical outcomes. A larger randomized trial is still needed to establish FFRCT's role in routine clinical care.
Coronary artery bypass grafting (CABG) with adjunctive endarterectomy (CE) is a useful technique for treating complex cases of diffuse coronary artery disease. CE aims to completely revascularize the heart by removing coronary artery blockages. While results of CE are debated, one study found acceptable mid-term results with CE and CABG, including a 2.7% in-hospital mortality rate. The study also compared outcomes of patients treated postoperatively with single antiplatelet therapy (aspirin) versus dual antiplatelet therapy (aspirin and clopidogrel). No significant differences in outcomes were found between the two groups in the mid-term follow up period, though dual antiplate
1) A study evaluated the impact of incorporating FFRCT data with CT angiogram results compared to CT angiogram alone in 200 patients.
2) The addition of FFRCT data led to a change in management in 36% of cases, similar to prior studies using invasive FFR.
3) This suggests non-invasive FFRCT can mimic invasive FFR's ability to refine management decisions made based on angiography alone. A definitive randomized trial is now needed to establish FFRCT's role as a default screening test for patients with chest pain.
Digital Image Processing Assessment in Multi Slice CT Angiogram using Liner, ...IJERA Editor
Nowadays with heart diseases most of peoples are dying lock process to find problem agile fashion in remote areas. In this research help to peoples who are staying remote also to find problem in heart on which location and how much problem to near and finally gives best analysis methodology for automated analysis for MultiSlice CT Angiogram images. Multi slice CT scanner is used to identify heart disease. Multi-detector CT is considered convenient and reliable non-invasive imaging modality for assessment of human angiogram 3D images. Automatic hart segmentation from Computed Tomography (CT) is highly demanded. Accurate hart segmentation is a crucial for computer-aided heart disease diagnosis and treatment planning. After segmentation and future extraction then identify whether the patient angiogram waveform has disease or not. For that, Support Vector Machine method is used to confirm the presence of disease. Neural Networks can solve different types of nonlinear problems in image classification and retrieval process. After that majorly focus on research learning methodologies for improve performance of the Multi Slice CT Angiogram images. So, in this research is summarizing the problem with liner of RBF neural network, Non-Liner SVM and RBF NN with liner and non-liner. Final, RBF NN with liner and non-liner provided more value and proved as best compare with other existing methodologies. This methodology consumes less time for both learning as well as testing comparatively than any other methods like back propagation. This issue drastically improves the estimation efficiency and accuracy for real time 128, 256 slices CT scan angiogram images.
This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.
Characteristics of coronary artery ectasia and its association with carotid i...Premier Publishers
This study was conducted to uncover the relation between coronary artery ectasia (CAE) and markers of atherosclerosis. A total of 1611 coronary angiograms were prospectively examined to find out patients with CAE. Those patients were divided into 2 groups: Mixed CAE with stenotic coronary artery disease (CAD) “group 1” and pure CAE “group 2”. Two control groups of age-adjusted subjects were selected consecutively in a 1:1 fashion; one with normal coronaries “group 3” (Pure CAE: normal coronaries) and the other with obstructive CAD only “group 4” (Mixed CAE: obstructive CAD). All recruited subjects underwent carotid intima-media thickness (IMT) and high sensitivity C-reactive protein (hs-CRP) level measurements. Out of examined angiograms, 35 subjects showed mixed CAE “group 1” and 26 showed pure CAE “group 2”. Age and gender-adjusted logistic regression analysis model revealed that significant independent predictors for CAE were: hypertension, smoking, absence of DM and hs-CRP level > 3 mg/L. Mean carotid IMT was significantly higher in group 2 than group 3 and in group 4 than group 1 (1±0.1 versus 0.4±0.2 mm and 1.4±0.4 versus 1±0.2 mm respectively, P < 0.001 for both). Mean hs-CRP level was significantly higher in group 1 than group 4 and in group 2 than group 3 (7±2 versus 3±0.8 mg/L and 6±2 versus 1±0.6 mg/L respectively, P < 0.001 for both). We concluded that atherosclerosis may not be the only plausible explanation for CAE.
Early Detection of Left Ventricular Dysfunction in Type II Diabetic Patients ...Premier Publishers
To assess Left ventricular (LV) systolic dysfunction using 2D speckle tracking echocardiography (STE) in asymptomatic type II Diabetic patients. We acquired three LV short-axis, and three LV apical views in 100 asymptomatic diabetic patients with normal LV ejection fraction (EF) and 25 age-matched healthy volunteers. We measured end-systolic longitudinal strain (LS), radial strain (RS), and circumferential strain (CS) in 18 LV segments. There were no significant differences in LVEF between two groups. Diabetic patients had more advanced diastolic dysfunction and increased LV mass compared with controlled group. Basal, middle, and apical LSs were significantly lower in diabetic patients compared with control subjects, with 43% (43/100) of the diabetic patients showing abnormal global LS values (cut-off value: 217.2 mean 2SD in control subjects Conclusion: Detecting subclinical LV systolic dysfunction by using 2D speckle tracking echocardiography (STE) might provide useful information of the risk stratification in an asymptomatic diabetic population.
1. The study tested whether bilateral near-infrared spectroscopy (NIRS) could reliably detect vascular injuries in extremities after trauma.
2. NIRS was used to continuously monitor tissue oxygen saturation (StO2) in both injured and uninjured extremities of 20 trauma patients with extremity injuries and 10 healthy volunteers.
3. Patients with vascular injuries had a significantly higher difference in StO2 between limbs (DStO2) compared to those without injury, indicating bilateral NIRS may help identify vascular injuries more reliably than single probe monitoring or physical exam alone.
This study describes the experiences of 24 patients treated for complex middle cerebral artery (MCA) aneurysms using bypass surgery combined with parent vessel occlusion. The aneurysms ranged in size from 7-60mm, with most being giant or fusiform. Bypass surgeries included extracranial-intracranial and intracranial-intracranial bypass procedures. Parent vessel occlusion involved partial or total trapping, with or without aneurysm resection. Outcomes were generally good, with 100% aneurysm obliteration and 21 patients (88%) having good functional outcomes, though permanent deficits occurred in 5 patients, most associated with M1 aneurysms. Location of the aneurysm was an important factor in planning treatment
Comparison of Invasive vs Noninvasive Pulse Wave Indices in Detection of Signifi cant Coronary Artery Disease: Can We Use Noninvasive Pulse Wave Indices as Screening Test
Computed tomography angiography (CTA) of the coronary arteries is a useful noninvasive tool to rule out significant coronary artery disease (CAD) in many clinical situations. Recent guidelines of stable CAD and non-ST segment elevation myocardial infarction endorse the use of CTA in symptomatic patients with low to intermediate likelihood of the disease, given the particularly high negative predictive value of the technique. However, in patients with high pre-test likelihood of CAD, the technique is not recommended, and one of the reasons is the high probability of coronary calcification in these patients, which interferes with the analysis of the images and reduces the specificity and negative predictive value of CTA.
(TOSHIBA CTEU140095) - Article from Toshiba's VISIONS Magazine#25, March 2015
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
This document summarizes research on using discrete cosine transform (DCT) to extract frequency domain features from electrocardiogram (ECG) signals for classifying cardiac arrhythmias. Features are extracted by computing the distance between RR waves. These frequency domain features are then classified using various soft computing techniques, including classification and regression trees, radial basis function networks, support vector machines, and multilayer perceptron neural networks. Experiments were conducted on the MIT-BIH arrhythmia database to evaluate the performance of these techniques for ECG-based arrhythmia classification.
- SYNTAX II is a single-arm international study comparing outcomes of contemporary PCI using the Synergy stent to the PCI arm of the original SYNTAX trial.
- The study aims to evaluate how improvements in stent platform/design, polymer coatings, and ischemia-guided revascularization impact outcomes compared to earlier generation DES.
- Preliminary data from one center shows physiological assessment with FFR/iFR may reclassify a significant portion of multivessel patients originally thought to require multi-vessel PCI based on angiography alone.
This document provides updated guidelines and reference values for cardiac chamber quantification by echocardiography. It summarizes recommendations for measuring and evaluating left ventricular size, function, mass and regional wall motion. Reference values are given for linear dimensions, volumes and ejection fraction of the left ventricle based on a large number of normal subjects. The document also summarizes guidelines for assessing right ventricular size and function, as well as the size and function of the left and right atria, aortic root dimensions, and inferior vena cava size. Partition values are only provided for left ventricular ejection fraction and left atrial volume due to limitations of existing data.
1. Gadolinium-based contrast agents accumulate in inflamed regions of arterial walls, highlighting areas of increased endothelial permeability, tissue water, and neovascularization associated with inflammation.
2. Studies have shown gadolinium contrast-enhanced MRI can identify arterial inflammation earlier than increases in wall thickness and is associated with elevated serum markers of inflammation.
3. Preliminary research also indicates superparamagnetic iron oxide (SPIO) nanoparticles, which are taken up by macrophages, may provide negative contrast enhancement of inflamed atherosclerotic plaques on MRI. Further clinical studies are still needed to validate these techniques.
In most cases evar substituted conventional repaire for ruptured aaa whyuvcd
The document discusses the increasing use of endovascular aneurysm repair (EVAR) to treat ruptured abdominal aortic aneurysms (rAAA) instead of open repair. EVAR is considered less invasive, resulting in less blood loss, shorter hospital stays, and lower mortality compared to open repair. While evidence comes from heterogeneous studies and a single-arm trial of 34 patients treated with the Anaconda device showed 91% treatment success but 30-day mortality of 17%, EVAR is increasingly used for rAAA due to the potential advantages over open repair. Randomized controlled trials are still needed to provide higher quality evidence.
COMPUTER AIDED DIAGNOSIS OF VENTRICULAR ARRHYTHMIAS FROM ELECTROCARDIOGRAM LE...sipij
In this work, we use computer aided diagnosis (CADx) to extract features from ECG signals and detect different types of cardiac ventricular arrhythmias including Ventricular Tachycardia (VT),Ventricular Fibrillation (VF), Ventricular Couplet (VC), and Ventricular Bigeminy (VB).Our methodology is unique in computing features of lower and higher order statistical parameters from six different data domains: time domain, Fourier domain, and four Wavelet domains (Daubechies, Coiflet, Symlet, and Meyer). These features proved to give superior classification performance, in general, regardless of the type of classifier used as compared with previous studies. However, Support Vector Machine (SVM) and Artificial Neural Network (ANN) classifiers got better performance than other classifiers tried including KNN and Naïve Bayes classifiers. Our unique features enabled classifiers to perform better in comparison with previous studies: for VT, 100% accuracy while best previous work got 95.8%, for VF, 100% accuracy while best
previous work got 97.5%, for VC, 100% sensitivity while best previous work got 71.8%, and for VB, 100%.sensitivity while best previous work got 84.6%.
Can we afford heart failure management in the futuredrucsamal
Heart failure is a major global health problem, affecting 26 million people worldwide. It accounts for 1-3% of hospital admissions in Europe and North America. Hospitalization is the main driver of the high economic costs of heart failure management, which is estimated to rise significantly in the coming decade. To better manage heart failure costs in the future, new models of coordinated and integrated care will need to be implemented, with a focus on preventing hospitalizations and readmissions through improved education, care transitions, and treatment of comorbidities.
European Journal of Heart Failure's year in Cardiologydrucsamal
This document contains information about Prof. Fausto J. Pinto who is the Head of Cardiology at University Hospital Sta Maria-HPV and University of Lisbon in Portugal. It discloses that he has received consultancy fees and lecture fees from various pharmaceutical companies. It also contains several figures and images from various medical studies and publications related to cardiology.
DSA Code of Conduct Responsibilities and DutiesThe DSEF
The document outlines the responsibilities and duties of member companies in complying with a Code of Ethics, including:
1. Establishing procedures to promptly investigate consumer complaints about improper conduct by salespeople.
2. Being responsible for code violations by solicitors and representatives, and not using independent contractor status as a defense.
3. Designating a Code Responsibility Officer and complying with complaint handling and publication requirements.
This document lists the minimum documentation required to maintain a quality management system (QMS) and occupational health and safety assessment series (OHSAS) certification. It includes requirements such as having an up-to-date quality policy and manual, conducting regular internal audits, maintaining training and purchase records, and documenting procedures for various safety topics like excavation work, oil handling, and working at heights. A total of 33 potential procedures or documents are outlined that may need to be prepared to meet the listed QMS and OHSAS documentation requirements.
Digital Image Processing Assessment in Multi Slice CT Angiogram using Liner, ...IJERA Editor
Nowadays with heart diseases most of peoples are dying lock process to find problem agile fashion in remote areas. In this research help to peoples who are staying remote also to find problem in heart on which location and how much problem to near and finally gives best analysis methodology for automated analysis for MultiSlice CT Angiogram images. Multi slice CT scanner is used to identify heart disease. Multi-detector CT is considered convenient and reliable non-invasive imaging modality for assessment of human angiogram 3D images. Automatic hart segmentation from Computed Tomography (CT) is highly demanded. Accurate hart segmentation is a crucial for computer-aided heart disease diagnosis and treatment planning. After segmentation and future extraction then identify whether the patient angiogram waveform has disease or not. For that, Support Vector Machine method is used to confirm the presence of disease. Neural Networks can solve different types of nonlinear problems in image classification and retrieval process. After that majorly focus on research learning methodologies for improve performance of the Multi Slice CT Angiogram images. So, in this research is summarizing the problem with liner of RBF neural network, Non-Liner SVM and RBF NN with liner and non-liner. Final, RBF NN with liner and non-liner provided more value and proved as best compare with other existing methodologies. This methodology consumes less time for both learning as well as testing comparatively than any other methods like back propagation. This issue drastically improves the estimation efficiency and accuracy for real time 128, 256 slices CT scan angiogram images.
This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.
Characteristics of coronary artery ectasia and its association with carotid i...Premier Publishers
This study was conducted to uncover the relation between coronary artery ectasia (CAE) and markers of atherosclerosis. A total of 1611 coronary angiograms were prospectively examined to find out patients with CAE. Those patients were divided into 2 groups: Mixed CAE with stenotic coronary artery disease (CAD) “group 1” and pure CAE “group 2”. Two control groups of age-adjusted subjects were selected consecutively in a 1:1 fashion; one with normal coronaries “group 3” (Pure CAE: normal coronaries) and the other with obstructive CAD only “group 4” (Mixed CAE: obstructive CAD). All recruited subjects underwent carotid intima-media thickness (IMT) and high sensitivity C-reactive protein (hs-CRP) level measurements. Out of examined angiograms, 35 subjects showed mixed CAE “group 1” and 26 showed pure CAE “group 2”. Age and gender-adjusted logistic regression analysis model revealed that significant independent predictors for CAE were: hypertension, smoking, absence of DM and hs-CRP level > 3 mg/L. Mean carotid IMT was significantly higher in group 2 than group 3 and in group 4 than group 1 (1±0.1 versus 0.4±0.2 mm and 1.4±0.4 versus 1±0.2 mm respectively, P < 0.001 for both). Mean hs-CRP level was significantly higher in group 1 than group 4 and in group 2 than group 3 (7±2 versus 3±0.8 mg/L and 6±2 versus 1±0.6 mg/L respectively, P < 0.001 for both). We concluded that atherosclerosis may not be the only plausible explanation for CAE.
Early Detection of Left Ventricular Dysfunction in Type II Diabetic Patients ...Premier Publishers
To assess Left ventricular (LV) systolic dysfunction using 2D speckle tracking echocardiography (STE) in asymptomatic type II Diabetic patients. We acquired three LV short-axis, and three LV apical views in 100 asymptomatic diabetic patients with normal LV ejection fraction (EF) and 25 age-matched healthy volunteers. We measured end-systolic longitudinal strain (LS), radial strain (RS), and circumferential strain (CS) in 18 LV segments. There were no significant differences in LVEF between two groups. Diabetic patients had more advanced diastolic dysfunction and increased LV mass compared with controlled group. Basal, middle, and apical LSs were significantly lower in diabetic patients compared with control subjects, with 43% (43/100) of the diabetic patients showing abnormal global LS values (cut-off value: 217.2 mean 2SD in control subjects Conclusion: Detecting subclinical LV systolic dysfunction by using 2D speckle tracking echocardiography (STE) might provide useful information of the risk stratification in an asymptomatic diabetic population.
1. The study tested whether bilateral near-infrared spectroscopy (NIRS) could reliably detect vascular injuries in extremities after trauma.
2. NIRS was used to continuously monitor tissue oxygen saturation (StO2) in both injured and uninjured extremities of 20 trauma patients with extremity injuries and 10 healthy volunteers.
3. Patients with vascular injuries had a significantly higher difference in StO2 between limbs (DStO2) compared to those without injury, indicating bilateral NIRS may help identify vascular injuries more reliably than single probe monitoring or physical exam alone.
This study describes the experiences of 24 patients treated for complex middle cerebral artery (MCA) aneurysms using bypass surgery combined with parent vessel occlusion. The aneurysms ranged in size from 7-60mm, with most being giant or fusiform. Bypass surgeries included extracranial-intracranial and intracranial-intracranial bypass procedures. Parent vessel occlusion involved partial or total trapping, with or without aneurysm resection. Outcomes were generally good, with 100% aneurysm obliteration and 21 patients (88%) having good functional outcomes, though permanent deficits occurred in 5 patients, most associated with M1 aneurysms. Location of the aneurysm was an important factor in planning treatment
Comparison of Invasive vs Noninvasive Pulse Wave Indices in Detection of Signifi cant Coronary Artery Disease: Can We Use Noninvasive Pulse Wave Indices as Screening Test
Computed tomography angiography (CTA) of the coronary arteries is a useful noninvasive tool to rule out significant coronary artery disease (CAD) in many clinical situations. Recent guidelines of stable CAD and non-ST segment elevation myocardial infarction endorse the use of CTA in symptomatic patients with low to intermediate likelihood of the disease, given the particularly high negative predictive value of the technique. However, in patients with high pre-test likelihood of CAD, the technique is not recommended, and one of the reasons is the high probability of coronary calcification in these patients, which interferes with the analysis of the images and reduces the specificity and negative predictive value of CTA.
(TOSHIBA CTEU140095) - Article from Toshiba's VISIONS Magazine#25, March 2015
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
This document summarizes research on using discrete cosine transform (DCT) to extract frequency domain features from electrocardiogram (ECG) signals for classifying cardiac arrhythmias. Features are extracted by computing the distance between RR waves. These frequency domain features are then classified using various soft computing techniques, including classification and regression trees, radial basis function networks, support vector machines, and multilayer perceptron neural networks. Experiments were conducted on the MIT-BIH arrhythmia database to evaluate the performance of these techniques for ECG-based arrhythmia classification.
- SYNTAX II is a single-arm international study comparing outcomes of contemporary PCI using the Synergy stent to the PCI arm of the original SYNTAX trial.
- The study aims to evaluate how improvements in stent platform/design, polymer coatings, and ischemia-guided revascularization impact outcomes compared to earlier generation DES.
- Preliminary data from one center shows physiological assessment with FFR/iFR may reclassify a significant portion of multivessel patients originally thought to require multi-vessel PCI based on angiography alone.
This document provides updated guidelines and reference values for cardiac chamber quantification by echocardiography. It summarizes recommendations for measuring and evaluating left ventricular size, function, mass and regional wall motion. Reference values are given for linear dimensions, volumes and ejection fraction of the left ventricle based on a large number of normal subjects. The document also summarizes guidelines for assessing right ventricular size and function, as well as the size and function of the left and right atria, aortic root dimensions, and inferior vena cava size. Partition values are only provided for left ventricular ejection fraction and left atrial volume due to limitations of existing data.
1. Gadolinium-based contrast agents accumulate in inflamed regions of arterial walls, highlighting areas of increased endothelial permeability, tissue water, and neovascularization associated with inflammation.
2. Studies have shown gadolinium contrast-enhanced MRI can identify arterial inflammation earlier than increases in wall thickness and is associated with elevated serum markers of inflammation.
3. Preliminary research also indicates superparamagnetic iron oxide (SPIO) nanoparticles, which are taken up by macrophages, may provide negative contrast enhancement of inflamed atherosclerotic plaques on MRI. Further clinical studies are still needed to validate these techniques.
In most cases evar substituted conventional repaire for ruptured aaa whyuvcd
The document discusses the increasing use of endovascular aneurysm repair (EVAR) to treat ruptured abdominal aortic aneurysms (rAAA) instead of open repair. EVAR is considered less invasive, resulting in less blood loss, shorter hospital stays, and lower mortality compared to open repair. While evidence comes from heterogeneous studies and a single-arm trial of 34 patients treated with the Anaconda device showed 91% treatment success but 30-day mortality of 17%, EVAR is increasingly used for rAAA due to the potential advantages over open repair. Randomized controlled trials are still needed to provide higher quality evidence.
COMPUTER AIDED DIAGNOSIS OF VENTRICULAR ARRHYTHMIAS FROM ELECTROCARDIOGRAM LE...sipij
In this work, we use computer aided diagnosis (CADx) to extract features from ECG signals and detect different types of cardiac ventricular arrhythmias including Ventricular Tachycardia (VT),Ventricular Fibrillation (VF), Ventricular Couplet (VC), and Ventricular Bigeminy (VB).Our methodology is unique in computing features of lower and higher order statistical parameters from six different data domains: time domain, Fourier domain, and four Wavelet domains (Daubechies, Coiflet, Symlet, and Meyer). These features proved to give superior classification performance, in general, regardless of the type of classifier used as compared with previous studies. However, Support Vector Machine (SVM) and Artificial Neural Network (ANN) classifiers got better performance than other classifiers tried including KNN and Naïve Bayes classifiers. Our unique features enabled classifiers to perform better in comparison with previous studies: for VT, 100% accuracy while best previous work got 95.8%, for VF, 100% accuracy while best
previous work got 97.5%, for VC, 100% sensitivity while best previous work got 71.8%, and for VB, 100%.sensitivity while best previous work got 84.6%.
Can we afford heart failure management in the futuredrucsamal
Heart failure is a major global health problem, affecting 26 million people worldwide. It accounts for 1-3% of hospital admissions in Europe and North America. Hospitalization is the main driver of the high economic costs of heart failure management, which is estimated to rise significantly in the coming decade. To better manage heart failure costs in the future, new models of coordinated and integrated care will need to be implemented, with a focus on preventing hospitalizations and readmissions through improved education, care transitions, and treatment of comorbidities.
European Journal of Heart Failure's year in Cardiologydrucsamal
This document contains information about Prof. Fausto J. Pinto who is the Head of Cardiology at University Hospital Sta Maria-HPV and University of Lisbon in Portugal. It discloses that he has received consultancy fees and lecture fees from various pharmaceutical companies. It also contains several figures and images from various medical studies and publications related to cardiology.
DSA Code of Conduct Responsibilities and DutiesThe DSEF
The document outlines the responsibilities and duties of member companies in complying with a Code of Ethics, including:
1. Establishing procedures to promptly investigate consumer complaints about improper conduct by salespeople.
2. Being responsible for code violations by solicitors and representatives, and not using independent contractor status as a defense.
3. Designating a Code Responsibility Officer and complying with complaint handling and publication requirements.
This document lists the minimum documentation required to maintain a quality management system (QMS) and occupational health and safety assessment series (OHSAS) certification. It includes requirements such as having an up-to-date quality policy and manual, conducting regular internal audits, maintaining training and purchase records, and documenting procedures for various safety topics like excavation work, oil handling, and working at heights. A total of 33 potential procedures or documents are outlined that may need to be prepared to meet the listed QMS and OHSAS documentation requirements.
The document discusses the importance of social media networks for businesses and professionals. It notes that social networks have become increasingly important in everyday life, from communicating with friends to promoting brands. The document recommends establishing a personal and company profile on popular social networks like Facebook, Twitter, Google+, and Instagram to strengthen a professional's digital identity, reach customers, share information and services, and communicate with other professionals and followers. Instagram in particular is highlighted as an easy way to share photos that can help businesses connect with users worldwide and discover new places and trends.
Este documento clasifica los tipos de bibliotecas según el material de su colección, la disciplina que abordan, y el perfil y servicios de sus usuarios. También describe cómo los bibliotecarios se especializan en facilitar información a estudiantes, investigadores y organizaciones a través de la gestión de información digital, aunque sus roles continúan redefiniéndose.
English Time School has worked with Ms. Reyes Cruz for over 18 months, selecting her to help open and manage their second academy location. As part of the expansion, Ms. Reyes Cruz coordinated services, marketing, statistics, and protocols between branches and created solutions to challenges. English Time School recommends Ms. Reyes Cruz due to her responsive, reliable, and professional nature, ability to quickly resolve problems, skilled staff, customer focus, experience with various technologies, and ability to efficiently handle different tasks under any circumstance.
1) The document discusses education reform in Hong Kong since 2000, focusing on developing students holistically through moral, intellectual, physical, and career-related education.
2) Key reforms include a new academic structure from primary to secondary education, greater school autonomy, expanded funding sources, and reforms to curriculum, pedagogy, and assessment to promote lifelong learning.
3) Challenges remain in connecting education improvements to student outcomes and ensuring education supports diversity, choice, and quality across the system.
Este documento describe la coherencia y cohesión textual. Explica que la coherencia se refiere al significado global de un texto y depende de que todas las partes del texto se relacionen con el tema central. También describe los tipos de coherencia como la global, local y pragmática. Además, explica que la cohesión proporciona continuidad de sentido a través de mecanismos léxicos y gramaticales como la repetición, familias léxicas y conectores.
This document discusses using diffusion tensor imaging (DTI) to analyze fractional anisotropy (FA) values in white matter regions of acute ischemic stroke patients. It finds that:
1) FA values are significantly lower in infarcted white matter and higher in hypoperfused white matter compared to normal white matter.
2) Hypoperfused white matter with a time-to-peak (Tmax) value greater than 5.4 seconds on perfusion maps had significantly higher FA values, suggesting early microstructural changes in ischemia.
3) DTI-FA analysis may help delineate microstructural changes in acute ischemic stroke, particularly differences between infarcted and hypoperfused white matter
This document discusses a study that used cardiac MRI and spectroscopy to assess myocardial triglyceride and creatine content in patients with cardiac amyloidosis compared to controls. The main findings were:
1. Patients with cardiac amyloidosis had increased left ventricular mass index and reduced global longitudinal and circumferential strain compared to controls, indicating systolic dysfunction.
2. Cardiac amyloidosis patients showed decreased myocardial triglyceride to water ratios compared to controls, but similar creatine to water ratios.
3. Lower triglyceride to water ratios correlated with worse global longitudinal and circumferential strain as well as increased left ventricular mass index.
1. Magnetic resonance angiography (MRA) is a non-invasive imaging technique that uses magnetic resonance imaging to visualize blood vessels and evaluate vascular anatomy and blood flow without using ionizing radiation or iodinated contrast material.
2. There are different MRA techniques including time-of-flight MRA, phase contrast MRA, and contrast-enhanced MRA. Time-of-flight MRA relies on differences in flowing and stationary blood signal while phase contrast MRA assesses velocity and direction of flow. Contrast-enhanced MRA uses gadolinium contrast to improve vessel depiction.
3. MRA has various clinical applications for evaluating carotid and intracranial arterial stenosis, aneurysms,
The MLS index was estimated by measuring the maximal separation of tip of the mitral leaflets in end diastole in parasternal long axis (PLAX) view and in apical 4-chamber view (A4C) (fig1). For patients in sinus rhythm, three
measurements was obtained in PLAX and A4C view each. An average
of this was taken as MLS index. For patients in atrial fibrillation, five measurements were taken in PLAX view and five measurements in A4C view. An average of this was considered as the MLS index. MLS index was compared with MVA assessed by planimetry and PHT.Severe MS was defined as MVA of 1cm2
or less by planimetry or pressure half-time. Moderate MS was defined as MVA between 1cm2 and 1.5cm2 by planimetry or pressure half-time method. Mild MS was
defined as an MVA of more than 1.5cm2 by planimetry or pressure halftime
Abstract
This issue of ‘Cardiovascular Diagnosis and Therapy (CDT)’ has a special focus on application and development of magnetic resonance imaging (MRI) in cardiovascular diseases. The challenges associated with imaging of the heart and the huge disease burden associated with cardiovascular diseases has been one of the major motivations in the last few years for the development of new MRI techniques. A realm of new pulse sequences, either focusing on ‘freezing’ motion or on providing improved endogenous contrast mechanisms were developed in this context and are now being evaluated in clinical and preclinical research efforts focusing on the heart and vascular circulation.
This document summarizes a study that evaluated the use of 256 slice MDCT pulmonary angiography (MDCT-PA) to diagnose pulmonary embolism (PE) in 100 unselected patients with clinically suspected PE. The study found that 35% of patients had thromboembolic disease, with 32% having acute PE and 8% having acute deep vein thrombosis (DVT). MDCT-PA allowed direct visualization of thrombi in the pulmonary arteries and veins. The study concludes that MDCT-PA is an effective first-line imaging method for evaluating patients suspected of having a PE due to its non-invasive nature and ability to directly identify thrombotic material.
This research article evaluated the diagnostic power of cardiac MRI to detect pulmonary hypertension in patients pre-selected by echocardiography. Fifty-six patients suspected of pulmonary hypertension based on echocardiography underwent right heart catheterization and cardiac MRI. The study extracted various MRI parameters proposed in previous studies as surrogates for pulmonary arterial pressure. Multivariate regression analysis identified right ventricle ejection fraction and pulmonary trunk minimum area as predictors of mean pulmonary arterial pressure, with an r-squared value of 0.5. However, the limits of agreement between MRI-predicted and catheterization-measured pressures were too wide. MRI was able to distinguish patients with normal and elevated pressures, achieving a specificity of 80% for detecting pulmonary hypertension at
This study aimed to determine if preoperative hematological parameters and risk factors could predict in-hospital mortality for patients undergoing surgery to repair Type A aortic dissection. The study reviewed data from 78 patients who underwent deep hypothermic circulatory arrest surgery. Only preoperative creatinine levels were higher in patients who died. Total circulatory arrest time and cross-clamp time during surgery were found to be factors affecting mortality, with times over 44.5 minutes and 71 minutes respectively predicting higher risk of death. The study concluded that hematological biomarkers alone may be insufficient for estimating mortality risk, and intraoperative factors like longer circulatory arrest and clamp times impact outcomes for Type A aortic dissection surgery.
Usefulness of Non-Enhanced 3-Dementional CT with Partial Maximum Intensity Pr...science journals
Computed Tomography (CT) with contrast material is often used for preoperative assessment and planning of embolotherapy in the treatment of Pulmonary Arteriovenous Malformations (PAVMs).
Unlike other modalities, MRI offers the capability to modulate both the emitted and received signals so that a multitude of tissue characteristics can be examined and differentiated without the need to change scanner hardware.
As a result, from a single imaging session, one could obtain a wealth of information regarding
cardiac function and morphology,
myocardial perfusion & viability,
hemodynamics,
large vessel anatomy.
CMR is now considered the gold standard for the assessment of regional and global systolic function, myocardial infarction (MI) and viability, and the assessment of congenital heart disease.
[123doc] - bai-giang-sieu-am-tim-3d-trong-danh-gia-va-can-thiep-cac-benh-ly-v...Thọ Văn
3D echocardiography plays an important role in assessing and intervening in valve diseases. It can evaluate valve anatomy in detail, guide interventional procedures such as MitraClip and balloon valvuloplasty, and monitor outcomes. Real-time 3D TEE is especially useful for quantifying mitral regurgitation and measuring the mitral valve area during balloon valvuloplasty. 3D imaging also helps with patient selection and guidance for transcatheter aortic valve implantation.
Imaging based selection of patients for acute stroke treatmentSachin Adukia
1) Several positive randomized controlled trials from 2015 established endovascular therapy (EVT) as effective for recanalization in patients with acute proximal anterior circulation artery occlusion.
2) Non-invasive neuroimaging is needed to exclude intracranial hemorrhage, confirm and localize treatable vessel occlusions, detect irreversible ischemic damage, and characterize salvageable tissue.
3) Recent studies have demonstrated that imaging-based selection of patients for EVT, including analysis of infarct core size, penumbra, and collateral flow, can effectively identify patients likely to benefit from the procedure beyond the 6 hour time window established in earlier trials.
1. Prof. Dr. Arif Faisal is a radiologist and professor in Indonesia who has extensive experience in radiology and hospital administration.
2. The document discusses various imaging technologies used for diagnosing and characterizing stroke, including CT, MRI, CTA, CTP, MRA and MRP.
3. CT is often used initially to differentiate between ischemic and hemorrhagic stroke, while MRI provides more detail and is better for detecting small lesions and stroke mimics. PWI-DWI mismatch on MRI can help identify potentially salvageable penumbra tissue.
This document discusses the role of MRI in assessing the thoracic aorta. It provides details on various MRI techniques used including CE-MRA, bSSFP, phase contrast, and black-blood sequences. It reviews clinical applications of MRI for thoracic aortic aneurysm, acute aortic syndromes, and large vessel vasculitis. MRI is presented as a good non-invasive alternative to CT for evaluation and serial imaging of thoracic aortic pathology due to lack of ionizing radiation and ability to characterize soft tissues and evaluate flow.
This study analyzed data from over 1,100 patients who underwent resection for intrahepatic cholangiocarcinoma (ICC) to evaluate the impact of lymph node metastasis (LNM) on outcomes. The results showed that patients with no LNM, 1-2 LNM, or 3 or more LNM had progressively worse survival. Examining at least 6 lymph nodes provided the best prognostic information. LNM beyond lymph node station 12 was associated with worse survival than LNM limited to station 12. The study concludes that routine lymph node dissection of at least 6 nodes including stations beyond 12 should be performed and that a new nodal staging system of N0, N1, and N2 based on number of positive
The study investigated the relationship between dilated Virchow-Robin spaces (VRS) seen on MRI and cerebral microvascular disease in elderly patients with dementia. 75 patients with Alzheimer's disease, ischemic vascular dementia, or frontotemporal dementia underwent MRI and were compared to 35 healthy volunteers. VRS scores were significantly higher in patients with vascular dementia compared to those with Alzheimer's disease, frontotemporal dementia, or healthy volunteers. VRS scores accounted for 29% of the variance in a regression model, more than periventricular hyperintensities, suggesting dilated VRS are a sensitive indicator of cerebral microvascular disease.
This document summarizes a study evaluating the use of MRI and MRS in characterizing intracranial ring-enhancing lesions. 50 patients with ring-enhancing lesions detected on CT or MRI were evaluated using conventional MRI sequences, diffusion-weighted imaging, and MRS. The most common lesions observed were tuberculomas (44%), followed by primary brain tumors (22%) and neurocysticercosis (12%). MRS found choline peaks in most lesions (56%), with lipid peaks also common. MRI and MRS patterns helped differentiate between benign and malignant lesions, with MRS providing additional metabolic information to aid characterization though not enabling diagnosis on its own.
Similar to Comparison of 7.0- and 3.0-T MRI and MRA in ischemic-type moyamoya disease: preliminary experience. (20)
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
This presentation gives information on the pharmacology of Prostaglandins, Thromboxanes and Leukotrienes i.e. Eicosanoids. Eicosanoids are signaling molecules derived from polyunsaturated fatty acids like arachidonic acid. They are involved in complex control over inflammation, immunity, and the central nervous system. Eicosanoids are synthesized through the enzymatic oxidation of fatty acids by cyclooxygenase and lipoxygenase enzymes. They have short half-lives and act locally through autocrine and paracrine signaling.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14...Donc Test
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
2. X. Deng et al
M
oyamoya disease (MMD) is an occlusive cere-
brovascular disease characterized by stenosis or
occlusion at the terminal portion of the bilateral
internal carotid arteries (ICAs) and the proximal portion
of the middle cerebral arteries (MCAs) and anterior ce-
rebral arteries (ACAs). Compensation for ICA occlusion
results in rich arterial collaterals at the base of the brain,
the so-called moyamoya vessels (MMVs), which means
“puff of smoke” vessels in Japanese.25,30
Although its eti-
ology is still uncertain, the disease is found predominantly
in Asian populations, which suggests the involvement of
hereditary and racial factors.19
There are 2 main clinical
phenotypes of MMD in Asian populations: the ischemic
type, which is common in children, and the hemorrhagic
type, which is seen mostly in adults.3,17,21,32
Conventional digital subtraction angiography (DSA)
has long been considered the gold standard for diagnos-
ing and assessing MMD. However, since the guidelines for
diagnosing MMD with MRI and MR angiography (MRA)
were published in 1997, time-of-flight (TOF) MRA has
been widely accepted as a noninvasive diagnostic modali-
ty. When ICA occlusion and MMVs are found with MRA,
conventional angiography is unnecessary, particularly in
pediatric patients.16
The interpretation of high-quality images is crucial
when diagnosing MMD with MRI/MRA without con-
ventional DSA. Precise evaluation of abnormal vascular
networks in the basal ganglia, in addition to vascular oc-
clusion, is essential for securing a definitive diagnosis of
MMD. Nowadays, 3.0-T MR techniques are widely used
in clinical situations, and have been reported to show su-
periority to 1.5-T MR in the diagnosis of MMD.7,31
In re-
cent years, however, 7.0-T MRI/MRA has been developed
and put into clinical use; it provides a better signal-to-
noise ratio and increased T1 relaxation time than does 3.0-
T MRI/MRA, which leads to higher-quality MR images,
especially in delineating small arteries.4,11,12
To our knowledge, except for one case report,20
no other
study has focused on comparing 7.0-T and 3.0-T MRI/
MRA in diagnosing MMD. Therefore, the purpose of our
study was to systematically compare 7.0-T and 3.0-T MRI
and TOF MRA images obtained in patients with ischemic-
type MMD.
Methods
All study protocols were approved by the institutional
review board of Beijing Tiantan Hospital, Capital Medi-
cal University, and written informed consent was obtained
from each patient and healthy volunteer. This study en-
rolled 15 patients with preoperative ischemic-type MMD
(MMD group) who were referred to the Department of
Neurosurgery at Beijing Tiantan Hospital between January
2013 and July 2014 and 13 healthy controls from the Uni-
versity of Chinese Academy of Sciences (control group).
Each subject underwent 3.0-T and 7.0-T MRI and MRA.
In addition, every patient with MMD underwent DSA. The
main arteries and MMVs and the diagnostic confidence
categories were evaluated on 3.0- and 7.0-T MR images
separately by 2 independent readers who were blinded to
field strength and the presence or absence of MMD.
MMD Group Selection
The diagnosis of MMD with conventional DSA was
based on the guideline reported by Fukui6
in 1997: 1) ste-
nosis or occlusion of the terminal ICA and the proximal
MCAs and ACAs and 2) bilateral involvement; patients
with any other disease that might explain the arterial ste-
no-occlusive disease were excluded. Also excluded were
patients with a history of intracranial hemorrhage and pa-
tients who had received surgical treatment for MMD. DSA
and 3.0-T and 7.0-T MRI/MRA were performed within 2
weeks of each other in all patients, and no clinical event
occurred between the 3 examinations.
Healthy Controls
Thirteen healthy volunteers from the University of Chi-
nese Academy of Sciences without any known cerebro-
vascular disease were enrolled. Each volunteer underwent
3.0-T and 7.0-T MRI/MRA within 1 week each other.
MRI/MRA Acquisition
Our study was performed with a 3.0-T Tim Trio (Sie-
mens) scanner and a 7.0-T Magnetom (Siemens) scanner
at the Beijing MRI Center for Brain Research, Institute
of Biophysics, Chinese Academy of Sciences. The 3.0-T
scanner was equipped with a volume coil for transmitting
and a 12-channel phased-array head coil for receiving.
The following parameters were used for 3.0-T TOF MRA:
TR 22.0 msec, TE 3.7 msec, flip angle 20°, FOV 220 × 220
mm2
, matrix 384 × 259, slice thickness 1 mm, and resolu-
tion 0.57 × 0.85 × 1.00 mm3
. In the 7.0-T Magnetom scan-
ner, a Nova 24-channel phased-array head coil was used
for transmitting and receiving, and the parameters were as
follows: TR 37 msec, TE 5.58 msec, flip angle 22°, FOV
200 × 200 mm2
, matrix 768 × 432, slice thickness 0.4 mm,
and resolution 0.26 × 0.46 × 0.40 mm3
.
Image Analysis
Image data were assessed on an OsiriX workstation
(version 6.0.1). All images were independently assessed
by 1 neuroradiologist and 1 neurosurgeon (each with more
than 5 years of experience) who were blinded to field
strength and the presence or absence of MMD; discrepan-
cies between the 2 readers were resolved by consensus.
As shown in Table 1, the steno-occlusive severity of in-
tracranial main vessels was evaluated on MRA according
to Houkin’s grading system (MRA score).14,34
Evaluations
of the 2 sides of the brain were performed separately, and
then only the symptomatic or the more severe hemisphere
was chosen for the following analysis. All scores were de-
termined mainly on MRA maximum-intensity projection
(MIP) images (Fig. 1), and 3D TOF images were also used
referentially.16
The MRA score was the sum of the ICA,
MCA, ACA, and posterior cerebral artery (PCA) scores.
Based on MRA scores, MRA stage grading was defined
in 4 grades to conveniently evaluate the progress of the
disease: MRA Grade 1, MRA score 0–1; MRA Grade 2,
MRA score 2–4; MRA Grade 3, MRA score 5–7; and
MRA Grade 4, MRA score 8–10.14,24
To assess the MMVs under identical circumstances, we
evaluated only transverse MIP images instead of reviewing
J Neurosurg November 6, 20152
3. Comparison of 7.0-T and 3.0-T MRI/MRA in moyamoya disease
all the angles of the MIP images (Fig. 1), and T2-weighted
MR images were also used referentially (Fig. 2A and B).
Based on previous studies, we obtained 2 MMV scores
to assess the visibility and image quality of the MMVs.
According to a study by Jin et al.,16
the MMV area score
was used to evaluate the visibility of MMVs; scores range
from 0 to 5 based on the 5 regions, including the basal
ganglion, anterior communicating artery, MCA–ICA tip,
posterior communicating artery (PCoA)–PCA, and basi-
lar artery tip areas, where collateral arteries are frequently
seen in patients with MMD. The image quality of MMVs
was evaluated with MMV quality scores, as follows: 3,
excellent (vessel segments are clearly and continuously
visualized, and vessel-tissue contrast appears to be high);
2, visible (vessel segments are visualized and adequate for
a confident diagnosis, but vessel–tissue contrast does not
appear to be particularly high); 1, scarcely visible (vessel
segments are visualized but inadequate for diagnosis); and
0, not visible.7
According to the guideline, the criteria for diagnosing
MMD with MRI and MRA are as follows: 1) stenosis or
occlusion at the terminal portion of the ICA and/or at the
proximal portion of the ACA and/or the MCA; 2) an ab-
normal vascular network in the basal ganglia (an abnor-
mal vascular network can be diagnosed when more than
2 flow voids are seen on 1 side of the basal ganglion on
MRI); and 3) bilateral appearance of Criteria 1 and 2.9,18
In this study, we used 2 methods to evaluate flow voids in
basal ganglia. One traditional way is to count the flow void
signals on T2-weighted axial MR images (Fig. 2C and D).
Another method is to count the high-signal-intensity ar-
eas in basal ganglia on source images from TOF MRA
(Fig. 3).23
Therefore, 2 criteria were used for diagnosing
MMD in this study: the T2 criteria and the TOF criteria.
Image selection from 3.0-T and 7.0-T MR data obtained
from the same subject was performed simultaneously, be-
cause identical section levels could be selected. Regions of
interest in the bilateral basal ganglia were selected care-
fully without including any cisternal structures. Accord-
ing to the Fushimi et al.7
study, when counting the high-
signal-intensity areas on source images, we determined
the threshold for the source images to make the brightest
part of brain parenchyma just black out to minimize the
variances of the thresholds (Fig. 3C and D). In accordance
with a Sawada et al.27
study, the confidence of each MMD
diagnosis based on MR images was classified into 1 of 5
categories (5, absolutely positive; 4, probably positive; 3,
unclear; 2, probably negative; and 1, absolutely negative).
In addition, MIP images of the superficial temporal
artery (STA) in lateral view were also evaluated on both
sides for each of the 28 subjects. The main STA, the fron-
tal branch, the parietal branch, and the subbranches were
assessed by the 2 observers.
Statistical Analysis
All statistical analyses were performed with MedCalc
Software (Windows version 14.8). MRA scores (including
ICA, MCA, and PCA scores), MRA grades, MMV area
scores, MMV quality scores, and diagnostic categories
according to the T2 and TOF criteria were compared be-
TABLE 1. Houkin’s MRA scoring for patients with MMD
Main Artery Findings Score
ICA Normal 0
Stenosis of C1 1
Discontinuity of C1 signal 2
Invisible 3
MCA Normal 0
Stenosis of M1 1
Discontinuity of M1 signal 2
Invisible 3
ACA Normal A2 & its distal signal 0
A2 & its distal signal decrease or loss 1
Invisible 2
PCA Normal P2 & its distal signal 0
P2 & its distal signal decrease or loss 1
Invisible 2
Total 0–10
A2 = infracallosal segment of the ACA; C1 = knee segment of the ICA; M1 =
horizontal segment of the MCA; P2 = ambient segment of the PCA.
Fig. 1. Patient 7. A and B: DSA images of a patient with MMD. DSA im-
ages, anteroposterior and lateral views, respectively, of the right carotid
arteries reveal stenosis of the right ICA associated with MMVs, discon-
tinuity of the MCA and ACA, and an enlarged PCoA (Suzuki’s Stage
III). C: A 3.0-T MRA MIP image showing discontinuity of the right MCA
horizontal segment (M1, arrowheads, MCA score of 2) and disappear-
ance of A2 (ACA score of 2), but the right PCoA was continuous (white
arrow, ICA score of 1). MMVs are visible at the right basal ganglion area
(MMV area score of 1, MMV quality score of 2). D: A 7.0-T MRA MIP
image shows similar main arteries (ICA score 1, MCA score of 2, ACA
score of 2), but the visualization of MMVs is better for the ICA–MCA tip,
basal ganglion, and PCoA–PCA tip (MMV area score of 3, MMV quality
score of 3).
J Neurosurg November 6, 2015 3
4. X. Deng et al
tween the 3.0-T and 7.0-T MR images by using the Wil-
coxon matched-pair signed-rank test. The paired t-test was
performed to compare the number of flow void signals on
T2-weighted MR images and the number of high-signal-
intensity areas on source images from TOF MRA be-
tween 3.0-T and 7.0-T MR images, with the left and right
sides analyzed independently. Concordance between the
2 observers for 3.0-T and 7.0-T MR images, with respect
to the MRA score, MMV area score, MMV quality score,
number of flow voids, number of high-signal-intensity
areas, and the diagnostic categories, was determined by
calculating the interclass correlation coefficient (ICC); an
ICC of > 0.75 indicates good interrater agreement.8
The
relationship between Suzuki’s stages, MRA grades, and
MMV area scores was evaluated with Spearman’s rank
correlation test. A correlation coefficient (rs) of > 0.8 in-
dicates strong correlation, and an rs of 0.6–0.8 indicates
a moderate correlation. A probability value of < 0.05 was
considered statistically significant.
Regarding the diagnostic accuracy of 3.0-T and 7.0-T
MRI/MRA, using DSA as the gold standard, receiver op-
erating characteristic (ROC) curves for both techniques
were created for statistical evaluation. The area under the
curve (AUC) and the 95% confidence interval (CI) for
each technique were calculated, and comparisons of the
AUCs of 3.0-T and 7.0-T MRI/MRA were performed with
Hanlay’s method.10
Moreover, cutoff points were calculat-
ed for each technique to maximize sensitivity and speci-
ficity. The T2 and TOF criteria were analyzed separately.
Results
Population
For the MMD group, 15 patients with ischemic-type
MMD who underwent both 3.0-T and 7.0-T MRI/MRA
were enrolled. As shown in Table 2, there were 8 males
and 7 females, with ages ranging from 13 to 48 years
(mean 29.1 ± 12.6 years). Clinical presentations included
transient weakness of limbs in 8 patients, headache in 4
patients, language dysfunction in 2 patients, and seizure
in 1 patient. According to Suzuki’s grading system, there
were 5 patients with Stage II, 5 with Stage III, 3 with Stage
IV, and 2 with Stage V MMD (Fig. 1A and B).
The control group included 13 healthy volunteers (7
males and 6 females) aged 19–28 years (mean 23.2 ± 2.5
years). No subject had neurological symptoms.
There were no significant differences between the
MMD and control groups in regards to sex (p = 1.000, by
Fisher’s exact test) or age (p = 0.095, by independent t-test).
Comparison of MRA Scores Between 3.0-T and 7.0-T MRA
As shown in Table 2, for the MMD group, the 3.0-T
MRA score ranged from 4 to 10, with 4 patients diagnosed
Fig. 2. Patient 7. Axial T2-weighted MR images of a patient with MMD. A and B: 3.0-T and 7.0-T images, respectively, showing
MMVs in the sylvian fissure; the 7.0-T MR image is much clearer. C: 3.0-T MR image revealing 1 clear and 4 blurry flow voids in
the right basal ganglion. D: 7.0-T MR image revealing 11 flow voids.
Fig. 3. Patient 7. Source images from TOF MRA of a patient with MMD.
3.0-T MR images (A and C) showing 2 high-signal-intensity areas, and
7.0-T MR images (B and D) demonstrating 15 high-signal-intensity ar-
eas in the right basal ganglion.
J Neurosurg November 6, 20154
5. Comparison of 7.0-T and 3.0-T MRI/MRA in moyamoya disease
with MRA Grade 2, 7 patients with Grade 3, and 4 pa-
tients with Grade 4 (Fig. 1C); the 7.0-T MRA score ranged
from 3 to 9, with 5 patients diagnosed with MRA Grade 2,
6 patients with Grade 3, and 4 patients with Grade 4 (Fig.
1D). According to the results of the Wilcoxon matched-
pair signed-rank test, there were no significant differences
between 3.0-T and 7.0-T MRA in regard to the ICA (p
= 0.564), MCA (p = 0.317), ACA (p = 0.317), PCA (p =
0.317), or MRA (p = 0.317) scores. No significant differ-
ence was found in the MRA grade, either (p = 0.317).
For the control group, no artery stenosis or occlusion
was observed; thus, the MRA score was 0 for all volun-
teers according to both 3.0-T and 7.0-T MRA.
Comparison of MMV Scores Between 3.0-T and 7.0-T MRA
For the MMD group, as shown in Table 3, the MMV
area score of 3.0-T MRA ranged from 0 to 3 (mean 1.47 ±
1.06) (Figs. 1C and 2A), and the MMV area score of 7.0-T
MRA ranged from 1 to 5 (mean 3.40 ± 1.40) (Figs. 1D and
2B). A significant difference was found between them (p =
0.001, by Wilcoxon matched-pair signed-rank test). Like-
wise, the MMV quality score of 7.0-T MRA (mean 2.73 ±
0.46) was also significantly higher than that of 3.0-T MRA
(mean 1.33 ± 0.98) (p = 0.001, by Wilcoxon matched-pair
signed-rank test).
For the control group, no MMVs were observed in any
case. Therefore, the MMV area score and MMV quality
score were both 0 for all the controls.
Comparison of Number of Flow Voids in Basal Ganglia
and Diagnostic Categories Between 3.0-T and 7.0-T MR
Images
T2 Criteria
The numbers of flow voids in bilateral basal ganglia
on T2-weighted MR images are shown in Table 4. For the
MMD group, 0 or 1 flow void was observed in 23 (76.7%)
sides on 3.0-T MR images and in 6 (20.0%) sides on 7.0-T
MR images. There were significantly more flow voids de-
tected in 7.0-T than in 3.0-T MR images (Fig. 2C and D)
on both the left (p < 0.001, by paired t-test) and the right (p
< 0.001, by paired t-test) sides. According to the T2 crite-
ria, the diagnostic categories were significantly higher in
7.0-T than in 3.0-T MR images (p = 0.005, by Wilcoxon
matched-pair signed-rank test).
TABLE 2. MRA scores and grades of the 15 patients with MMD according to 3.0-T and 7.0-T MRA*
Pt
No.
Age
(yrs) Sex Hemisphere
Suzuki
Stage
3.0-T MRA Score 7.0-T MRA Score
ICA MCA ACA PCA
MRA
Score
MRA
Grade ICA MCA ACA PCA
MRA
Score
MRA
Grade
1 17 M Rt III 0 3 2 0 5 3 1 3 2 0 6 3
2 38 F Lt V 3 3 2 2 10 4 3 3 2 1 9 4
3 34 F Rt IV 3 3 2 0 8 4 3 3 2 0 8 4
4 13 F Lt III 1 3 2 0 6 3 1 3 2 0 6 3
5 44 M Rt II 1 3 0 0 4 2 1 3 0 0 4 2
6 13 M Lt III 1 2 1 1 5 3 1 3 1 1 6 3
7 21 M Rt III 1 2 2 0 5 3 1 2 2 0 5 3
8 18 F Lt IV 3 3 1 0 7 3 2 3 2 0 7 3
9 48 M Rt II 1 3 0 0 4 2 1 3 0 0 4 2
10 40 M Lt IV 3 3 2 2 10 4 2 2 2 2 8 4
11 13 F Rt II 1 2 1 0 4 2 1 1 1 0 3 2
12 36 F Lt III 1 3 1 0 5 3 1 3 1 0 5 3
13 36 M Rt II 1 3 0 0 4 2 1 3 0 0 4 2
14 42 M Rt II 1 3 1 0 5 3 1 2 1 0 4 2
15 23 F Rt V 3 3 2 0 8 4 3 3 2 0 8 4
Pt = patient.
* Only the symptomatic or the more severe hemisphere was chosen for analysis.
TABLE 3. MMV area and quality scores according to 3.0-T and
7.0-T MRA for patients with MMD*
Pt No.
MMV Area Score MMV Quality Score
3.0-T MRA 7.0-T MRA 3.0-T MRA 7.0-T MRA
1 2 5 1 3
2 2 5 2 3
3 1 5 1 3
4 2 3 2 3
5 0 1 0 2
6 3 4 2 3
7 1 3 2 3
8 3 4 3 3
9 0 2 0 2
10 2 5 3 3
11 0 2 0 3
12 1 3 1 3
13 1 2 1 2
14 1 2 1 2
15 3 5 2 3
* Only the symptomatic or the more severe hemisphere was chosen for
analysis.
J Neurosurg November 6, 2015 5
6. X. Deng et al
For the control group, flow voids in bilateral basal
ganglia on T2-weighted images were observed in only 1
control individual (Control 13), with 1 flow void in each
side, which were revealed by both 3.0-T and 7.0-T MRI.
Because no artery stenosis or occlusion was observed on
MRA, the diagnostic category was 1 for all controls for
both 3.0-T and 7.0-T MR images.
TOF Criteria
Similarly, as shown in Table 4, for patients with MMD, 0
or 1 high-signal-intensity area was observed in 14 (46.7%)
sides on 3.0-T and only 1 (3.3%) side on 7.0-T TOF MRA
source images. The number of high-signal-intensity areas
detected in 7.0-T TOF source images was significantly
greater than that of 3.0-T TOF MRA source images (Fig.
3) on both the left (p < 0.001, by paired t-test) and right
(p < 0.001, by paired t-test) sides. According to the TOF
criteria, the diagnostic categories were significantly higher
in 7.0-T than in 3.0-T MR images (p = 0.011, by Wilcoxon
matched-pair signed-rank test).
For the control group, 0 or 1 high-signal-intensity area
was observed in 25 (96.2%) sides on 3.0-T and 21 (80.8%)
sides on 7.0-T TOF MRA source images. The number of
high-signal-intensity areas detected in 7.0-T TOF MRA
source images was also significantly higher than that
of 3.0-T TOF MRA source images on both the left (p =
0.014, by paired t-test) and right (p = 0.002, by paired t-
test) sides. The diagnostic categories are shown in Table
4. Although there were 3 controls in category 2 and 1 con-
trol in category 3 according to the 7.0-T MR images, and
only 1 control in category 2 according to the 3.0-T MR
images, no significant differences were observed between
them (p = 0.102, by Wilcoxon matched-pair signed-rank
test).
TABLE 4. Flow voids in bilateral basal ganglia on T2-weighted MR images and high-signal-intensity areas on source
images from TOF MRA and the diagnostic categories of 3.0-T and 7.0-T MRI/MRA
Group No.
No. of Flow Voids on
T2-Weighted MR Images
Diagnostic
Category*
No. of High-Signal-Intensity
Areas on TOF MRA
Source Images
Diagnostic
Category†
3.0-T 7.0-T 3.0-T
MR
7.0-T
MR
3.0-T MR 7.0-T MR 3.0-T
MR
7.0-T
MRLt Rt Lt Rt Lt Rt Lt Rt
MMD 1 0 0 5 4 1 5 3 2 6 10 5 5
2 1 0 3 4 2 5 5 4 26 20 5 5
3 1 1 7 9 3 5 2 1 18 15 4 5
4 0 3 3 4 3 5 3 5 7 13 5 5
5 0 0 3 4 1 5 0 0 3 7 1 5
6 3 3 4 8 5 5 2 4 12 26 5 5
7 0 5 6 11 3 5 2 2 7 15 5 5
8 1 0 7 7 2 5 1 0 12 9 2 5
9 1 0 1 3 2 4 0 1 1 4 2 4
10 3 4 5 6 5 5 5 5 13 21 5 5
11 0 1 2 4 2 5 1 1 7 8 3 5
12 0 0 3 2 1 5 0 0 8 7 1 5
13 0 0 1 1 1 3 0 0 6 5 1 5
14 0 0 0 0 1 1 0 0 4 5 1 5
15 4 1 4 1 4 4 4 2 8 2 5 5
Control 1 0 0 0 0 1 1 0 0 0 0 1 1
2 0 0 0 0 1 1 0 0 1 1 1 1
3 0 0 0 0 1 1 0 0 2 2 1 3
4 0 0 0 0 1 1 0 0 1 0 1 1
5 0 0 0 0 1 1 1 1 1 1 1 1
6 0 0 0 0 1 1 0 0 1 1 1 1
7 0 0 0 0 1 1 0 0 1 1 1 1
8 0 0 0 0 1 1 0 0 1 2 1 2
9 0 0 0 0 1 1 0 0 1 1 1 1
10 0 0 0 0 1 1 0 0 0 0 1 1
11 0 0 0 0 1 1 0 0 0 0 1 1
12 0 0 0 0 1 1 0 0 1 2 1 2
13 1 1 1 1 1 1 2 1 1 2 2 2
* According to T2 criteria.
† According to TOF criteria.
J Neurosurg November 6, 20156
7. Comparison of 7.0-T and 3.0-T MRI/MRA in moyamoya disease
ICCs for 3.0-T and 7.0-T MRI/MRA
The ICCs of MRA scores, MMV area scores, MMV
quality scores, number of flow voids, number of high-sig-
nal-intensity areas, and diagnostic categories between the
2 observers are shown in Table 5; there was good interrater
reliability for both 3.0-T and 7.0-T MRI/MRA.
Comparison of STA Visualization Between 3.0-T and 7.0-T
MRA
Both 3.0-T (Fig. 4A) and 7.0-T (Fig. 4B) MRA revealed
the main STA and the frontal and parietal branches clearly
in all 56 hemispheres. In addition, 7.0-T MRA also re-
vealed the subbranches of the STA in 41 hemispheres, but
they could not be seen with 3.0-T MRA.
ROC Curve Analysis of 3.0-T and 7.0-T MRI/MRA
Figure 5 shows ROC curves for the 2 techniques ac-
cording to T2 criteria. The AUC of 3.0-T MRI/MRA was
0.800 (95% CI 0.607–0.926; p = 0.001). The AUC of the
7.0-T MRI/MRA was 0.992 (95% CI 0.862–1.000; p <
0.001). The difference between the 2 AUCs was 0.192,
and a significant difference between the 2 techniques was
identified by using Hanlay’s method (p = 0.024). In addi-
tion, cutoff points were calculated for each technique to
maximize sensitivity and specificity using ROC curves.
The sensitivity, specificity, and Youden index were 0.692,
0.933, and 0.626 according to 3.0-T MRI/MRA (calculat-
ed cutoff point > 1) and 1.000, 0.933, and 0.933 according
to 7.0-T MRI/MRA (cutoff point > 1), respectively.
Figure 6 shows ROC curves for the 2 evaluation meth-
ods according to TOF criteria. The AUC was 0.851 (95%
CI 0.666–0.956; p < 0.001) for the 3.0-T MRI/MRA and
1.000 (95% CI 0.877–1.000; p < 0.001) for the 7.0-T MRI/
MRA. The difference between the 2 AUCs was 0.149, but
no significant difference was observed (p = 0.052). More-
over, for the diagnosis of MMD, the sensitivity, specificity,
and Youden index were 0.733, 0.923, and 0.656 according
to the 3.0-T MRI/MRA (cutoff point > 1) and 1.000, 1.000,
and 1.000 according to the 7.0-T MRI/MRA (cutoff point
> 3), respectively.
Relationship Between Suzuki’s Stage and MRA Grade and
Area Score
For patients with MMD, Spearman’s rank correlation
test showed a strong correlation between Suzuki’s stage
and MRA grade in both 3.0-T (rs = 0.930; p < 0.001) and
7.0-T (rs = 0.966; p < 0.001) MRA. The correlation be-
tween Suzuki’s stage and MMV area score was moderate
for 3.0-T MRA (rs = 0.738; p = 0.002) and strong for 7.0-T
MRA (rs = 0.908; p < 0.001).
Discussion
MRI and MRA are now widely used for the diagnosis
of MMD because of their advantages over conventional
DSA, which include noninvasiveness, no requirement for
a contrast medium, no radiation exposure, and visual pri-
ority for detecting other MR findings (infarction, hemor-
rhage, and cerebral atrophy).7,26
It has been reported that
the depiction of small MMVs is better with 3.0-T MRA
than with 1.5-T MRA, mainly because the signal-to-noise
Fig. 4. MIP images of the left STA in lateral view. Both 3.0-T (A) and 7.0-T (B) MRA images delineate the main STA (asterisk) and
the frontal and parietal branches clearly. However, 7.0-T MRA also reveals 2 subbranches of the frontal branch, 1 subbranch of the
parietal branch (arrowheads), and the superficial temporal vein (arrow), which cannot be seen by 3.0-T MRA.
TABLE 5. ICCs between the 2 observers for 3.0-T and 7.0-T MRI/MRA
Item
ICC Btwn Observers (95% CI)
3.0-T MRI/MRA 7.0-T MRI/MRA
MRA score 0.987 (0.973–0.994) 0.989 (0.978–0.995)
MMV area score 0.878 (0.755–0.941) 0.977 (0.951–0.989)
MMV quality score 0.919 (0.833–0.961) 0.991 (0.981–0.996)
No. of flow voids in bilat basal ganglia on T2-weighted images 0.924 (0.844–0.964) 0.986 (0.970–0.993)
No. of high-signal-intensity areas in bilat basal ganglia on source
images of TOF MRA
0.951 (0.899–0.977) 0.993 (0.985–0.997)
Diagnostic category according to T2 criteria 0.976 (0.949–0.989) 0.995 (0.990–0.998)
Diagnostic category according to TOF criteria 0.994 (0.987–0.997) 1.000 (1.000–1.000)
J Neurosurg November 6, 2015 7
8. X. Deng et al
ratio of 3.0-T MR images is approximately twice that
of 1.5-T MR images.1,7,33
However, in recent years, 7.0-
T MRI/MRA has been developed and provides a better
signal-to-noise ratio and increased T1 relaxation time than
does 3.0-T imaging, which leads to higher-quality MR im-
ages, especially of the small intracranial vessels on TOF
MRA.5,28
To our knowledge, with the exception of 1 case
report,20
no other study has focused on comparing 7.0-T
and 3.0-T MRI/MRA in patients with MMD. Therefore,
we performed this study to compare the image quality of
3.0-T and 7.0-T MRI/MRA, with emphasis on their depic-
tion of MMVs and their sensitivity and specificity for the
diagnosis of MMD.
Our results show that there was no significant im-
provement in the depiction of main intracranial arteries
on 7.0-T MRA, as demonstrated by the MRA scores (p =
0.317) and MRA grades (p = 0.317). Both 3.0-T and 7.0-T
MRA grades had a strong correlation with Suzuki’s stage
(rs = 0.930 and 0.966, respectively). Compared with 3.0-T
MRA, 7.0-T MRA showed many more small arteries and
depicted the MMVs much more clearly, as demonstrated
by both the MMV area score (p = 0.001) and MMV qual-
ity score (p = 0.001). These findings were also consistent
with the results of previous studies, which showed that
7.0-T TOF MRA provided only small increases in the sig-
nal-to-noise ratio in the primary intracranial vessels but
provided better visualization of the first- and second-order
branch arteries.11,12,22,36,37
Meanwhile, in our study, MMVs
in the sylvian fissure, interpeduncular cistern, and quadri-
geminal cistern (Fig. 2A and B) were visualized better on
axial T2-weighted 7.0-T MR images.
MRA grades according to 3.0-T MRA have been prov-
en to be associated with Suzuki’s stage.16
Our results cor-
respond with those of previous studies, and 7.0-T MRA
did not have a significantly stronger correlation with Suzu-
ki’s stage. The MMV score was excluded from the MRA
grade, because the development of MMVs was not signifi-
cantly correlated with Suzuki’s stage.13
However, in a study
by Jin et al.,16
there was a good correlation between the
MMV score and Suzuki’s stage. In our study, the relation-
ship between Suzuki’s stage and the MMV area score was
moderate for 3.0-T MRA and strong for 7.0-T MRA. We
speculate that the probable reason is that the majority (13
of 15) of the patients with MMD were in Suzuki’s Stages
II to IV, in which the number of MMVs can reflect the
severity of the disease.
In addition, visualization of the STA is important, be-
cause the STA plays an important role in the surgical treat-
ment of MMD, via either STA–MCA bypass or encephalo-
duroarteriosynangiosis. Although there was no systematic
evaluation of the STA in ultra-high-field TOF MRA, sev-
eral studies have confirmed better contrast in peripheral
segments of intracranial vessels in higher main fields.29,35
Our results show that both 3.0-T and 7.0-T MRA can de-
pict the main STA and the frontal and parietal branches
clearly. However, compared with 3.0-T MRA, 7.0-T MRA
showed a greater ability to detect the tiny branches of the
STA; subbranches of the STA on 41 hemispheres were de-
tected by 7.0-T MRA but not by 3.0-T MRA. Therefore,
we believe that 7.0-T MRA may provide additional infor-
mation on the STA, which is useful for surgical treatment.
Regarding the diagnosis of MMD with MRI and
MRA, the key point is to detect flow voids in the basal
ganglion.2
However, previous studies showed that flow
voids in the basal ganglion cannot always be observed on
MR images, which lowers the diagnostic sensitivity of the
criteria.23,27
According to the existing guidelines, the sen-
sitivity of 3.0-T MRI/MRA was only 0.45 in the Sawada
et al.27
study (specificity 1.00) and 0.72 in the Mikami et
al.23
study (specificity 0.74). In our study, according to the
Fig. 6. ROC curves of 3.0-T and 7.0-T MRI/MRA according to TOF cri-
teria. Figure is available in color online only.
Fig. 5. ROC curves of 3.0-T and 7.0-T MRI/MRA according to T2 crite-
ria. Figure is available in color online only.
J Neurosurg November 6, 20158
9. Comparison of 7.0-T and 3.0-T MRI/MRA in moyamoya disease
T2 criteria, the diagnostic sensitivity of 3.0-T MRI/MRA
was 0.692 (specificity 0.933). The low diagnostic sensi-
tivity of 3.0-T MRI/MRA limited its application in the
diagnosis of MMD.
In contrast, with respect to 7.0-T MRI/MRA, the diag-
nostic sensitivity was significantly improved according to
both the T2 (sensitivity 1.000; specificity 0.933) and TOF
(sensitivity 1.000; specificity 1.000) criteria. The high sen-
sitivity and specificity of 7.0-T MRI/MRA might be bene-
ficial for the diagnosis of MMD. If MMD can be diagnosed
definitively by using only 7.0-T MRI/MRA, conventional
DSA can be skipped, and the adverse effects of DSA, such
as contrast media allergy, can be avoided. Moreover, di-
agnosing MMD by using 7.0-T MRI/MRA alone may be
particularly beneficial for younger patients, because DSA
usage in pediatric patients may be complicated by narrow
arteries and their need for sedation. In addition, it may be
beneficial for patients with slow progression, who can be
followed up using MRI/MRA alone and treated conserva-
tively without surgical therapy. In conclusion, diagnosing
MMD by using 7.0-T MRI/MRA alone may be beneficial
for accurate first diagnosis and subsequent imaging fol-
low-ups. Therefore, we speculate that 7.0-T MRI/MRA is
a promising technique for diagnosing MMD, because it is
noninvasive compared with conventional DSA and has a
much higher sensitivity than 3.0-T MRI/MRA.
This study has several limitations. First, it is based on
retrospective research with limitations inherent to the study
design. Second, the number of patients with MMD was
restricted, because only those who underwent DSA and
3.0-T and 7.0-T MRI/MRA were enrolled. Because 7.0-T
MRI/MRA is not a routine clinical technique at present,
many patients refused to undergo this examination. The
small sample size may have led to false-negative findings
of the difference of AUCs between the 2 techniques ac-
cording to the TOF criteria. Third, the parameters of 3.0-T
and 7.0-T MRI cannot be matched exactly because of tech-
nology limitations and the retrospective design. Moreover,
although the readers were blinded to the field strength,
there are some differences in image quality between 7.0-T
and 3.0-T images. It is possible that the readers were influ-
enced by these differences. In addition, the study was fo-
cused on preoperative imaging, and none of these patients
underwent postoperative 7.0-T MRI/MRA. Therefore, we
could not assess collateralization postoperatively. Last, we
cannot deny the possibility of overestimation of steno-oc-
clusion on MRA, as previously reported.15
Conclusions
Compared with 3.0-T MRI and MRA, 7.0-T MR images
did not show significant improvement in depicting the ma-
jor intracranial arteries and the main STA, but it detected
and delineated MMVs much more comprehensively, and
the tiny branches of the STA were also better visualized.
The diagnostic sensitivity was improved significantly by
7.0-T MRI/MRA. We speculate that 7.0-T MRI/MRA is a
promising technique for diagnosing MMD because of its
noninvasiveness compared with conventional angiography
and much higher sensitivity compared with that of 3.0-T
MRI/MRA.
Acknowledgment
This study was supported by the Ministry of Science and
Technology of China (Grant 2012CB825505), the National Key
Technology Research and Development Program of the Ministry
of Science and Technology of China (Grant 2013BAI09B03), and
the Center of Stroke, Beijing Institute for Brain Disorders (Grant
BIBD-PXM2013_014226_07_000084).
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Disclosure
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Zhao, Deng, Z Zhang, R Wang. Acquisi-
tion of data: Deng, Z Zhang, B Wang, K Wang. Analysis and
interpretation of data: Deng, Ye, Xu, K Wang. Drafting the arti-
cle: Deng. Critically revising the article: Zhao, Deng, Y Zhang,
D Zhang, R Wang, Xu, B Wang, K Wang. Reviewed submitted
version of manuscript: Zhao, Deng, Y Zhang, D Zhang, R Wang,
Xu, B Wang, K Wang. Approved the final version of the manu-
script on behalf of all authors: Zhao. Statistical analysis: Deng, R
Wang, Ye, K Wang. Administrative/technical/material support:
Z Zhang, Ye, K Wang. Study supervision: Zhao, Z Zhang, Y
Zhang.
Correspondence
Jizong Zhao, Department of Neurosurgery, Beijing Tiantan Hos-
pital, Capital Medical University, No. 6 Tiantan Xili, Chongwen
District, Beijing 100050, China. email: zhaojz205@163.com.
J Neurosurg November 6, 201510